ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2021-10-30

Framework: KLOE · 18 pages · 83 KB · PDF

Good

safe: Goodeffective: Goodcaring: Goodresponsive: Goodwell-led: Good

Fairthorn, a small extra care housing domiciliary service in Sheffield, was rated Good across all five key questions at its November 2017 inspection. The service had successfully remediated a prior breach of Regulation 13 (safeguarding) identified in 2016, with strong leadership, person-centred care, and effective governance systems now in place.

Concerns (4)

criticalSafeguarding: “breach of Regulation 13...Safeguarding service users from abuse and improper treatment...registered manager had not ensured the systems and processes in place were operated effectively”
moderateMedication management: “seven [safeguarding notifications] were regarding medicines errors, poor recording, and poor moving and handling techniques”
moderateRecord keeping: “seven were regarding medicines errors, poor recording, and poor moving and handling techniques”
minorStaff training: “there were two members of staff on the matrix who were overdue in completing one area of training”

Strengths

· People consistently reported feeling safe and well cared for, with staff demonstrating kindness, dignity and respect at all times
· Robust safeguarding improvements made since the previous inspection; no longer in breach of Regulation 13
· Comprehensive recruitment procedures including DBS checks, references and proof of identity
· Medicines administration records fully completed and staff regularly observed by the registered manager
· Staff received regular supervisions (minimum four per year) and annual appraisals, tracked via a 1:1 tracker

Quality-Statement breakdown (17)

safe: SafeguardingGood
safe: Staffing levels and recruitmentGood
safe: Medicines managementGood
safe: Risk assessmentGood
effective: Staff training and inductionGood
effective: Supervision and appraisalGood
effective: Mental Capacity Act complianceGood
effective: Nutrition and health supportGood

Inspection report · 2021-10-30

Framework: KLOE · 14 pages · 80 KB · PDF

Requires improvement

safe: Requires improvementeffective: Goodcaring: Goodresponsive: Goodwell-led: Requires improvement

Fairthorn, a domiciliary care agency supporting eight people in an extra care scheme, was rated Requires Improvement overall following its first rated inspection in October 2016, with a breach of Regulation 13 identified due to two safeguarding concerns not being reported to the local authority. While caring, effective and responsive practice were rated Good, significant concerns remained around safeguarding governance, an insufficient management handover, and medication recording errors.

Concerns (6)

criticalSafeguarding: “two safeguarding concerns had not been reported to the local authority...Staff had recorded concerns in one person's incident record within their care plan in April 2016, but we found no evidence that this information had been reported”
moderateGovernance: “the handover of information to the new manager was insufficient...checks the area manager told us they had completed, for example, care plan audits were not recorded”
moderateLeadership: “At the moment though, it's a proper mess. The manager has changed, and she doesn't understand how this works really”
moderateMedication management: “some medication errors at the service. For example, a staff member not signing the person's medication administration record to confirm the person had been given their medication”
moderateRecord keeping: “staff did not record when they withdrew monies from a person's monies account...administrator told us they had not been given a copy of the policy as part of their induction”
minorCare planning: “People had risk assessments in place. We found that they could be more personalised and less generic.”

Strengths

· Robust recruitment procedures in place with appropriate DBS checks and references before staff started work
· Staff received ongoing training, supervision and appraisal; new manager proactively reviewed training records
· People told us they were treated with dignity and respect and made positive comments about staff
· People were involved in care planning and changes to care plans were responded to promptly
· Robust complaints process in place with investigation and action taken on complaints

Quality-Statement breakdown (16)

safe: Safeguarding people from abuse and improper treatmentRequires improvement
safe: Risk assessmentsRequires improvement
safe: Medication managementRequires improvement
safe: RecruitmentGood
effective: Health and dietary supportGood
effective: Staff trainingGood
effective: Supervision and appraisalGood
effective: Mental Capacity Act complianceGood

Inspection reports (3)